Friday, October 15, 2010

In last week's post I presented the flow chart (at link below), exhibiting the path from the production of health care proper to human well-being, and I asked where in this process one should monitor the performance that we might seek to encourage through financial incentives.

I noted that adherence to what is thought to be best clinical practice for given medical conditions is the most widely used approach to measuring performance, even though it is generally agreed that a better way is to measure performance by clinical outcomes — that is, changes in the health status of patients (Box B in the chart). Much work is now under way to move in that direction.

Unfortunately, measuring performance by clinical outcome is easier said than done.

All of these experiments (mentioned in the article) with pay-for-performance are fledgling efforts, because the science of outcome measurement has yet to scale many methodological hurdles. Furthermore, in practice the approach will work only if the providers of health care find them sufficiently accurate and fair to sign on. And economic theory tells us that to make the approach effective, it must be backed with significant financial incentives. So far, in many instances, the sums of money at stake have been rather small.

Several readers of last week's post saw in my enumeration of the difficulties of measuring performance a rejection of the idea. Not at all. The task is indeed daunting, but that does not mean we should back away from it. Rather, we must be patient and not expect too much too soon.

Where are the science and art of medicine headed? Is the health care professional's role to asses the needs of the patient and try to meet those needs? That alone is a daunting task when you consider studies that show that patients are receiving only about half of the care that they should be receiving.

Will the guidelines for medical care become a complex algorithm of process and outcomes, with the health care professional understanding that the goal and rewards will be found in mastering and optimally executing the measurement junctures within that massive maze? Will these measurements be samplings, or will almost everything be measured (a not so far-fetched concept in this day of computerization)? What burden in time and effort will this entail?

How about the real world? When the child with diabetes who you have been caring for comes in because of being depressed over the fact that her parents just split up, are you going to ignore her immediate overwhelming concern because you are too busy checking to see that you are complying with the glycohemoglobin and whatever other process and outcome junctures on which you will be rewarded?

When the goal is to do our best to see that everyone has the highest quality care that we can manage to pay for, it would be sad to see us caught up in the science of measurements when the greater need is in the art of medicine.

We must thank Dr. Reinhardt for 2 stimulating posts on P4P. He has pointed out the problems of P4P. But I fear he still believes that P4P could work, despite growing evidence to the contrary. Physicians have multidimensional tasks with each patient. We must make accurate diagnoses; we must treat diagnoses and symptoms; we must communicate with patients and help them make diagnostic and treatment decisions. We must balance the treatment of multiple diseases and weigh the risks and benefits each potential treatment decision.

Implementing a P4P scheme focuses attention on the measurables and decreases attention to those things that are not measured. The NHS P4P project demonstrates that very well. Focusing on prompt visits led to a decrease in physician-patient continuity. Focusing on some parameters led to a degradation in other parameters.

P4P sounds like it should work, but many physicians believe that it cannot work, because no metric can evaluate the extent of our professional responsibilities.

We could look at preventable errors (such as central line infections) and penalize hospitals for unacceptable rates. But we should only do that when we can establish that we have a proven method to achieve the goal. I picked this example because of Dr. Peter Provonost's excellent work on this particular issue.

Dr. Reinhardt suggests that we use outcomes, but what outcomes should we measure. How do we place a metric on accurate diagnosis? We can study the reasons for diagnostic error, but measuring diagnostic errors represents a most complex and perhaps unsolvable problem?

How do we measure the physician patient interaction? This interaction includes history taking, patient education and patient motivation. Some suggest we use patient satisfaction scores, but those have major flaws and suffer from intense grade inflation.

How do we measure an appropriate balancing for the management of 5 (or more) diseases? How do we assess the appropriate prioritization of medications? How do we value decreasing polypharmacy by not treating every performance indicator to its fullest?

How do we value appropriate referrals to palliative care? How do we put a number on excellent comfort care?

I thank Dr. Reinhardt for shining a light on this problem. While I disagree with his belief that P4P is a solvable problem, I agree that we have not yet solved the problem.

Comment: As part of the current fervor over implementing reform, considerable attention has been directed to controlling spending and improving quality by changing reimbursement methods from those based on volume and complexity of services to models based on measurements of clinical practices and health care outcomes.

Professor Reinhardt suggests that we must not expect too much out of these efforts in the immediate future; I indicate that the science and art of medicine provide far greater benefits than those measurements of process and outcomes could ever adequately assess; and Dr. Centor provides a precise explanation of why current concepts of P4P (pay for performance) miss the target.

The magic of the highly touted accountable care organizations seems to be based on these same principles. It is likely that the magic will turn out to be only sleight-of-hand, at best.

Our policymakers would be much more productive if they would shift their attention from dinking around with P4P to crafting a financing system that would ensure that everyone would have affordable access to an efficient health care delivery system with a robust primary care infrastructure. PNHP can help our policymakers define that system, if only they will finally listen.